BMJ 1998; 317 doi: https://doi.org/10.1136/bmj.317.7164.1024 (Published 10 October 1998) Cite this as: BMJ 1998;317:1024

Why do outpatients fail to keep clinic appointments, asks a report in International Journal of Clinical Practice (1998;52:436-7). The answers are disappointingly predictable: they forget the appointment, feel too ill to make it, or never receive details of it in the first place. In a questionnaire study of nearly 1000 patients who missed their outpatient appointments a third of those scheduled to have a review appointment simply forgot and a fifth were too ill to attend. A tenth of them had travel difficulties, and 1% blamed the weather. Their general lack of enthusiasm was also reflected in the 38% response rate in the survey.

Doctors who would like to find a good home for back copies of the British National Formulary should contact Elaine Harden at the Commonwealth Pharmaceutical Association, who is organising an annual collection of recent editions for the developing world. All the books will be distributed to pharmacists and other health professionals in commonwealth countries (tel 0171 820 3399; email eharden{at}compuserve.com

Good news is rare in adolescent substance misuse, but recent data suggest that the prevalence of misuse may have reached a plateau (Canadian Medical Association Journal 1998;159:451-4). A survey of nearly 4000 Canadian schoolchildren found that most substances, including alcohol, tobacco, and cannabis, were no more popular in 1997 than in 1995. The prevalence of glue sniffing actually went down over the same two year period. The authors emphasise, however, that these figures are probably no more than a small break in the clouds and warn healthcare professionals not to get complacent.

Minerva was further encouraged by a study of 1000 pregnant women in the south of England that found that nearly a third deliberately took folic acid supplements before conception (British Journal of Obstetrics and Gynaecology 1998;105:954-9). More women are also taking supplements in early pregnancy: nearly three quarters in this study, which was completed in February 1996. Younger women, smokers, and women with poor educational backgrounds were least likely to take supplements and, as usual, present a tougher challenge to health educators. There is still no evidence of a decline in the incidence of neural tube defects, say the authors, but then no one has looked for one since 1994.

A popular herbal treatment for prostate cancer has important clinical effects mediated by oestrogenic activity, researchers from New Jersey in the United States have found (New England Journal of Medicine 1998;339:785-91). Eight patients with prostate cancer who took the remedy PC-SPES for at least a month reported breast tenderness and loss of libido. Their serum testosterone concentrations decreased during treatment, and so did serum concentrations of prostate specific antigen. Laboratory and biological assays in mice showed that PC-SPES behaves like an oestrogen, and trialists studying prostate cancer should be alert to the possibility that trial participants may be taking it.

New experimental data in Nature (1998;395:381-3) confirm that cannabis is a painkiller, acts centrally, and works by stimulating the same brainstem circuitry as morphine, but in a different way. Investigators from California, United States, found that inactivating the rostral ventromedial medulla in rats stopped the analgesic effect of a cannabinoid but not its motor effects. Cannabis dulls pain but also the motor reflexes that enable a rat to flick its tail away from a painful stimulus. Previously the two effects were always observed together, making it difficult to prove that cannabis was an effective analgesic.

Glen Hoddle, England's national football coach, must be getting used to press criticism for his unorthodox approach to team fitness. He comes under fire once again in the British Journal of Sports Medicine for recruiting a faith healer to care for his world cup team (1998;32:195). An editorial argues that faith healing is not just a harmless diversion for pampered footballers; it can do real damage if used inappropriately, particularly in children. Campaigners trying to protect children from overzealous practitioners can do without international sports giants endorsing their treatments, it says.

Legal claims in obstetrics and gynaecology account for over two thirds of the money spent by the NHS on litigation, but does that mean lawyers are treated with kid gloves when having babies? Not according to a letter in the Lancet, which compares the delivery experience of 62 lawyers, 52 doctors, and 62 control women from neither profession. The data suggest that lawyers are treated no differently from anyone else. They had more normal deliveries and fewer caesarean sections than doctors, but, wisely, the authors chose not to attempt statistical analysis on such small numbers.

People taking low fat diets who can't resist cheeseburgers are sometimes frustrated by the refusal of fat free cheese to melt seductively over low fat burgers (Postgraduate Medicine 1998;104:40). An American doctor suggests they try marinading the cheese in soup or water first. The rehydrated product should melt as well as ordinary full fat cheese.


A 23 year old patient with acne vulgaris had one of her back teeth removed by a dentist who noticed the dental pigmentation shown clearly in the photograph. The patient had been taking Minocycline for 4 years to treat her acne. Hyper pigmentation is a well described side effect, and skin pigmentation occurs in up to half of patients taking Minocycline for more than 3 years. Other sites that develop pigmentation include fingernails, sclerae, and teeth. Blue black discolouration of adult teeth is usually permanent and patients should be warned of the possibility before treatment, and monitored regularly during treatment.

M M U Chowdhury, specialist registrar, K B Das, associate specialist, D L Roberts, consultant dermatologist, Singleton Hospital, Sketty, Swansea SA2 8QA

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Drugs are often used as an alternative to surgery in patients with mild carpal tunnel syndrome. Non-steroidal anti-inflammatory drugs, diuretics, and oral steroids are equally popular. A randomised controlled trial in 73 patients comparing these three treatments found that only oral steroids improved symptoms over four weeks (Neurology 1998;51:390-3). Patients took 20 mg prednisolone for two weeks and 10 mg for two weeks. The next step, say the authors, is to compare oral steroids with other conservative measures such as splinting and local steroid injection.

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